Complete Recovery of Multiple Cranial Nerve Palsies in Tuberculous Meningitis Using Levofloxacin as a Second-Line Anti-Tuberculosis Drug: A Case Report

Abstract

Introduction: Tuberculous meningitis (TBM) is a severe form of extrapulmonary tuberculosis (TB) with high mortality and morbidity rates. Clinical manifestations of TBM vary, both typical and atypical. Second-line anti-TB drugs are generally used in cases of drug-resistant TB but may serve as an alternative if side effects occur from the standard regimen. Presentation: A 26-year-old woman presented with decreased consciousness, hallucinations, diplopia, and vertigo. Neurological examination revealed bilateral sixth nerve palsy and left eye ptosis. The diagnosis of TBM was confirmed based on clinical symptoms, brain magnetic resonance imaging (MRI) results showing basal leptomeningeal enhancement, and the detection of Mycobacterium tuberculosis (M. tuberculosis) in cerebrospinal fluid (CSF) and sputum. The patient initially received standard therapy with rifampicin, isoniazid, pyrazinamide, and streptomycin (RHZS), but developed side effects including drug-induced liver injury (DILI) and drug eruption. The rifampicin regimen was temporarily switched to levofloxacin as a second-line anti-TB drug for nearly two months, and streptomycin was discontinued. During this therapy, significant clinical improvement was observed, including the resolution of cranial nerve palsy. The rifampicin, isoniazid, pyrazinamide, and ethambutol (RHZE) regimen was then resumed and completed over 9 months without residual symptoms. Discussion: The use of second-line anti-TB drugs such as levofloxacin can be an effective temporary alternative in drug-sensitive TBM if there is intolerance to the first-line regimen. Fluoroquinolones are a compelling treatment option for TBM, primarily due to their favorable penetration into the central nervous system.